Provider Demographics
NPI:1164517181
Name:MEYER, MICHAEL G (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MEYER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 KILLEBREW DR
Mailing Address - Street 2:STE 308
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1886
Mailing Address - Country:US
Mailing Address - Phone:651-999-7022
Mailing Address - Fax:651-999-6970
Practice Address - Street 1:6025 LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1710
Practice Address - Country:US
Practice Address - Phone:651-999-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10199363A00000X
MN920363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical